0256-95740256-9574S0256-957420090008000010008200900082009998543543FROM THE EDITOR

Health systems: chaos requires software renewal

Militant actions by medical practitioners1 were predictable, and it is surprising that they did not manifest sooner. It is a pity that they erupted on the first watch of the new Minister of Health and his deputy, Drs Aaron Motsoaledi and Molefi Sefularo, before they have had a chance to show their paces (or will this in fact be a true test of their capacity?). How did this sorry state arise, and what can heal these wounds?

The disastrous reign of the former Minister of Health, Dr Manto Tshabala-Msimang, and her Director-General Thami Mseleku, was labelled a 'lethal combination' in a newspaper evaluation of ministerial performances. Apart from the AIDS denial debacle, the hardware of the public health care system (hospitals, clinics, equipment, medicines, etc.) has deteriorated seriously. Contributing factors are the usual software culprits (people and their competencies or lack thereof). Foremost was the central control and autocratic rule of the National Department of Health, and in some provinces that led to a climate of fear and a sense of lack of respect for their qualities and skills on the part of medical practitioners. But a close second has been the appointment of managers and other senior staff in the health sector on grounds other than competence. Since aggression is often employed to mask the insecurities of those completely out of their depth (or of ideological conviction), relationships break down and trust is destroyed. Hence the pull factors for professionals to remain in the public sector were trumped by those pushing them out.

Policies and practices, sometimes with the best of intentions, have further aggravated the situation. The government has chosen the collective bargaining process governed by the Labour Relations Act that requires medical practitioners to be lumped as a trade union in order to negotiate service conditions and wages. This reduces their professional status, and leads to prolonged bargaining processes and the use of collective mass action when relationships become dysfunctional.

Some time before the advent of our democracy Van Zyl Slabbert predicted that the true test of the new (present) government would be the delivery of services, particularly at the local level. The mismanagement of local authorities leading to unrest in the townships, failure of the SABC, ESKOM's power failures and the continuing SA Airways functional incapacity have been amply documented. This issue of SAMJ documents a collapse of clean water systems in many parts of the country,2 and a decline in academic medicine is noted in two other contributions.3,4 Such examples of systemic dysfunction send a loud wake-up call to government.

Fortunately there is evidence that this call has been heard politically, as evidenced by President Zuma's addresses that include an emphasis on hard work and eliminating graft and corruption. Many of his ministerial appointments, including health, have also been positive. The Department of Health is at last seriously engaging the medical profession in discussions after years of neglect.

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The global economic crisis motivated Jim Collins to analyse factors contributing to the failure of some institutions while others succeed.5 Decline, it turns out, is largely self-inflicted, and the path to recovery lies largely within our own hands. By applying some of these findings we can all contribute to the long haul of transforming the environment and rebuilding our health sector. Firstly, transformation is essential. But transformation is not merely about skin colour  it is essentially the appointment of the right person to the right place, and we must move to ensuring appointments on merit (and removing the incompetent). The right people fit with our core values and don't need to be tightly managed, as they understand that they have responsibilities and fulfil their commitments. In teams on the way up people bring forth grim facts to be discussed and leaders do not criticise them; in teams on the way down people shield those in power from unpleasant facts, fearful of penalties and criticism. Winners bring data, evidence, logic, and solid arguments whereas losers assert strong opinions without evidence or solid argument. Other dynamics of leadership-team behaviour of teams on the way up are that team members unify behind a decision once made; that each team member credits other people for success, yet enjoys the confidence of peers (as opposed to taking as much credit as possible for themselves); that the team conducts 'autopsies without blame', mining wisdom from painful experiences (losers seek culprits and blame); and that each team member delivers exceptional results, yet in the event of a setback each accepts full responsibility and learns from mistakes.

Our health systems will benefit from such a software renewal, which in turn will fix the hardware.